Bria of Cahokia

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medication and discard expired medication. This has the potential to affect all 109 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide reasonable accommodation of resident needs by not providing residents with their call light in reach for 4 of 23 residents (R20, R32, R41, R92) reviewed for call lights in reach in the sample of 40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided with a safe/clean/home like environment and has the potential to affect all residents that consume meals in the dining room. Findings Include: 1. R20's Face Sheet, admission date of 03/10/25, documents R20 has diagnoses of but not limited to difficulty in walking, unsteadiness on feet, and dementia. R20's Minimum Data Set (MDS), dated [DATE], documents R20 is severely cognitively impaired and requires assistance with her activities of daily living (ADLs). R20's Care Plan, admission date of 03/10/25, documents R20 displays difficult behaviors when dealing with peers and/or staff over perceived fault findings. R20 is known to hoard items and will often refuse to allow staff to enter her room to clean or perform care. She has been noted to refuse medication most times. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for 4 of 10 (R1, R10, R32, R92) reviewed for resident safety in the sample of 40.

Inspectors wroteBased on interviews, observation and record review, the facility failed to complete hand hygiene and change gloves for 3 of 7 residents (R6, R92, R48); reviewed for Infection Control in a sample size of 40.

Inspectors wroteBased on interview and record review the facility failed to notify the provider of an incident timely for 1 out of 2 residents (R53) reviewed for Resident Rights in a sample of 40.

Inspectors wroteBased on interview and record review, the facility failed to complete a mandatory resident assessment with the pre-admission screening and resident review (PASARR) for residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 of 8 residents (R7, R101) reviewed for completion of PASARR in the sample of 40.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure each resident's care plan is reviewed and revised after each resident assessment and/or change in condition for 4 of 23 residents (R1, R10, R34, R108) reviewed for updated resident care plans in the sample of 40.

Inspectors wroteBased on observation, interview and record review the facility failed to perform complete and timely incontinent care for 2 of 2 (R6, R92) residents reviewed for toileting in a sample of 40.

Inspectors wroteBased on interviews and record review the facility failed to administer the correct medication for 2 of 2 residents (R53, R21); reviewed for Pharmacy Services in a sample of 40.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain cleanliness and to distribute food under sanitary conditions regarding cleanliness. This failure has the potential to affect all 113 residents residing in the facility.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. This has the potential to affect all 113 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to properly assess and supervise a resident during an out of state physician's appointment for 1 of 4 residents (R2) reviewed for supervision in a sample of 16. This failure resulted in R2 who is known of returning from day passes intoxicated, not returning to the facility on [DATE] directly after the appointment with non-emergency ambulance transportation provider or staff escort and instead returning on public transportation after going sightseeing. The Immediate Jeopardy began on 08/19/25 when Due to the facility's failure to properly assess and supervise a resident (R2) during an out of state physician's appointment. This failure resulted in R2 not returning to the facility on [DATE] and instead going sightseeing on public transportation. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide supervision to prevent elopement for 1 of 5 residents (R5) reviewed for supervision to prevent accidents in a sample of 8. This failure resulted in R5 eloping through the front entrance at 2:38 AM, on 8/13/25, unsupervised and returning to the facility at 3:36 AM after staff found him approximately 1.2 miles from the facility. The Immediate Jeopardy began on 8/13/25 at 2:38 AM when R5, a confused resident, exited the facility unsupervised and was found 1.2 miles away. R5 returned back to the facility with staff at 3:36 AM. On 8/19/25 at 9:03 AM, V1 (Administrator) was notified of the Immediate Jeopardy. The surveyor confirmed by observation, interview and record review that the Immediate Jeopardy was removed on 8/20/25.

Inspectors wroteBased on interview and observation the facility failed to assist with financial matters for 1 out of 1 residents (R2) reviewed for social services in the sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to have call light within reach for 1 of 3 residents (R2) reviewed for resident rights in the sample of 6.

Inspectors wroteBased on interview and record review, the Facility failed to prevent verbal abuse for 1 of 5 residents (R9) by (R6) for two residents (R9, R6) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interview and record review, the Facility failed to report reasonable suspicion of a crime to law enforcement for 1 of 5 residents (R4) reviewed for abuse policy in the sample of 9.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 4 out of 4 residents, (R1, R3, R4, and R5); reviewed for resident rights in a sample of 5.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to treat 3 out of 3 residents, (R2, R3, and R4) with dignity and respect; reviewed for resident rights in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to prevent resident-to-resident abuse for four of four residents (R18, R28, R56, R81) reviewed for abuse in the sample of 42. Findings Include: 1. The Abuse Investigation Final Report, dated 2/5/25, documents the following: R18 was upset that she was out of cigarettes and was talking inappropriately out loud. R28 told her to stop, and R18 made contact with R28. R28 attempted to get up and make contact back and she slid out of her wheelchair. R18 was sent out for a psychiatric evaluation. No injuries were noted. Upon final investigation it was found the above information was correct. R18's Face Sheet, undated, documents R18 has the following diagnoses: Paranoid Schizophrenia, Dementia, Bipolar Disorder, Unspecified Psychosis and Schizoaffective Disorder. [...]

Inspectors wroteBased on interview, and record review the facility failed to supervise residents during showering to prevent falls for 1 of 11 residents (R83) reviewed for falls in the sample of 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to discontinue use of a resident's insulin after it was expired for 1 of 5 residents (R28) reviewed for labeling and storage of medications in the sample of 42.

Inspectors wroteBased on interview and record review the facility to justify the use of antibiotics for 3 of 4 residents (R10, R72, R306) reviewed for antibiotic stewardship in the sample of 42.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure garbage in the facility dumpster was covered. This had the potential to affect all 105 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 6 of 6 residents (R1, R2, R3, R4, R5, R6) reviewed for pest control in Facility in the sample of 6.

Inspectors wroteBased on observation, interview, record review, the facility failed to provide incontinence care to 2 of 3 residents (R1, R4) reviewed for incontinent care in the sample of 6.

Inspectors wroteBased on observation, interview and record review the facility failed to assess resident's skin upon admission, failed to provide ongoing assessments, failed to follow/update physician's treatment orders, failed to complete physician ordered pressure ulcer treatments and failed to put interventions in place to prevent skin breakdown for 3 of 3 residents (R1, R2 and R3) reviewed for pressure ulcers in a sample of 3. This failure resulted in R2 developing a deep tissue injury (DTI) to R2's right hip which worsened by increasing in size. evolved to an unstageable pressure ulcer and the left hip pressure ulcer a DTI evolved to a Stage 3 pressure ulcer.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to maintain a clean and sanitary environment during wound care, and to wear Personal Protective Equipment (PPE) for residents who are on Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R3, R5, R37) reviewed for wound care in the sample of 19.

Inspectors wroteBased on interview and record review the Facility failed prevent resident to resident verbal and physical abuse for 8 of 13 residents (R1, R23, R24, R28, R29, R33, R43, R44) reviewed for abuse in the sample 51. This failure resulted in R43 throwing a punch, falling from his chair, and fracturing his hip.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide follow-up urology care per standards of practice for 1 of 3 residents (R28) reviewed for quality of life in the sample of 51. This failure resulted in a delay of R28's scrotal surgery, ongoing unnecessary pain which affects R28's quality of life.

Inspectors wroteBased on interview and record review the Facility failed to ensure all alleged violations were thoroughly investigated for 4 of 13 residents (R1, R5, R12, R29) reviewed for abuse investigations in the sample of 51.

Inspectors wroteBased on interview and record review the Facility failed to implement progressive interventions to prevent falls, failed to implement safe mechanical lift transfer techniques, and ensure equipment is in good repair to prevent injury for 4 of 7 residents (R6, R7, R25, R30) reviewed for supervision to prevent falls/accidents in the sample of 51.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly store medications for 6 of 6 residents (R4, R11, R34, R36, R37, R38) observed for proper medication storage in the sample of 51. The Findings Include: 1. R11's admission Record, dated 2/3/25, documents R11 was admitted to the facility on [DATE] and discharged on 1/29/25 with diagnosis of Compartment Syndrome of right lower extremity, Type 2 Diabetes Mellitus (DM), Accidental discharge from firearms, Deep Vein Thrombosis, Malignant neoplasm of colon, Vascular implants and grafts, Hypertension (HTN), and Peripheral Vascular Disease (PVD). R11's Care Plan, dated 1/22/25, documents R11 is at risk for bleeding/bruising related to anticoagulation medication use. He takes Lovenox as ordered. He has a history embolism. R11's Minimum Data Set (MDS), dated [DATE], documents R11 was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat pressure ulcers per physician's orders for 1 of 4 residents (R35) reviewed for pressure ulcers in the sample of 51.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to maintain a clean and sanitary environment during wound care, and to wear Personal Protective Equipment (PPE) for residents who are on Enhanced Barrier Precautions (EBP) for 3 of 3 residents (R3, R5, R37) reviewed for wound care in the sample of 19.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program related to roaches and mice in the facility. This failure has the potential to affect all 110 residents residing in the facility.

Inspectors wroteBased on interview, and record review the facility failed to provide coffee and condiments per menu for 8 of 9 residents (R1, R2, R4, R5, R6, R7, R8, and R9) reviewed for following the menu in the sample of 9. Findings Include: The menu provided for Week 1 documented that for breakfast, lunch and dinner coffee and condiments should be served. Milk should be served for breakfast and dinner. On 11/14/2024 at 8:30 AM R4 stated that they always receive coffee first before the breakfast tray. R4 added that the facility runs out of cream, sugar and milk. On 11/14/2024 at 8:30 am R5 was sitting in the dining room. R5 stated that two days ago, he didn't receive milk with his cereal. On 11/14/2024 at 8:15 am, R6 stated that his breakfast should have been served by now. He stated that sometimes they run out of sugar and cream. R6 stated they run out of milk all of the time. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure an alleged abuse allegation was thoroughly investigated for 1 of 3 residents (R2) reviewed for verbal abuse in the sample of 6.

Inspectors wroteBased on record review and interviews the facility failed to assess and treat pain and provide pain medication according to physician's order for 1 of 3 (R3) resident reviewed for pain management in a sample of 11. This failure resulted in R3 experiencing severe and unbearable pain. 10/10 on pain scale of 1-10.

Inspectors wroteBased on interview and record review the facility failed to administer medication as prescribed for 1 of 3 (R3) residents reviewed for medication administration in a sample of 11.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents are free from sexual abuse for 2 of 3 residents (R3, R4) reviewed for sexual abuse in the sample of 10. The failure resulted in R4 touching R3 in a sexual manner without R3's consent causing R3 to trigger memories of past sexual traumas, feelings of fear, worthless, being dirty with increased showering, and attempting to avoid R4 as he remains in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide timely incontinent care to 3 of 5 residents (R2, R3, R4) reviewed for ADL (Activities of Daily Living) care in the sample of 13. This failure resulted in R2 having psychosocial harm, making her feel sad and hopeless.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor meal intakes to identify concerns with nutrition in 1 of 5 residents (R5), reviewed for nutrition/hydration status maintenance in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered in 3 of 7 residents (R3, R4, R10) reviewed for pharmacy services in the sample of 13.

Inspectors wroteBased on interview and record review the Facility failed to ensure pain was assessed, recognizing the onset, presence, and duration of pain, and assessing the characteristics of the pain for 1 of 3 residents (R7) reviewed for pain in the sample of 36. R7 has a cancer diagnosis and verbalized being in intense pain due to lack of pain medication being available for administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide supervision to prevent elopement for 1 of 3 residents (R2) reviewed for elopement in the sample of 36.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered by the physician. The facility also failed to have a working system in place to ensure required prescriptions for renewal of medication are timely signed by a medical provider to ensure medications are requested from the pharmacy in a timely manner and are consistently available for administration for 4 of 4 residents (R6, R7, R8 and R9) reviewed for medications in the sample of 36.

Inspectors wroteBased on observation, interview, and record review the Facility failed to follow CDC Infection Control Guidelines during an COVID outbreak and staff failed to wear the proper PPE (Personal Protective Equipment) during patient care for 4 of 18 residents (R33, R34, R35 and R36) reviewed for COVID in the sample of 36.

Inspectors wroteBased on interview and record review the facility failed to ensure the correct medication was administered to the right resident for 1 of 12 residents (R2) reviewed for medications in a sample of 13. R2 was given R3's blood pressure medication and anti-psychotic medication. R2 was sent to the emergency room for evaluation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow current care plan interventions/physician orders to maintain a resident's weight and to prevent significant weight loss for 1 of 8 residents (R76) reviewed for nutrition in the sample of 52. This failure resulted in R76 losing 14.84% body weight in 3 months.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food is stored and prepared in a manner which prevents potential contamination and potential food borne illness. This has the potential to affect all 88 residents living in the facility.

Inspectors wroteBased on observation, interview, and record review the Facility failed to assure residents were receiving diet as ordered to maintain normal body weight and acceptable nutritional values and menus/recipes were followed for 4 of 5 residents (R12, R53, R75, R76) reviewed for nutritional needs in the sample of 52.

Inspectors wroteBased on interview and record review the facility failed to provide residents with working toilets for 5 of 5 residents (R16, R29, R50, R86, and R99) reviewed for safe, functional, sanitary, comfortable, environment in the sample of 52.

Inspectors wroteBased on interview and record review the Facility failed to prevent resident to resident abuse for 2 of 5 residents (R31 and R87) reviewed for abuse in the sample of 52.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of physical abuse for one of 5 residents (R66) reviewed for abuse in the sample of 52.

Inspectors wroteBased on interview and record review, the facility failed to provide supervision to prevent a resident from eloping from the facility for 1 of 2 residents (R208) reviewed for elopement in the sample of 52.

Inspectors wroteBased on interview and record the facility to provide timely refills of narcotic pain medication for one of one resident (R97) reviewed for pharmacy services in the sample of 52.

Inspectors wroteBased on interview and record review the facility failed to ensure residents' request for meal of the month was honored and implemented when asked by the facility for 5 of 5 residents (R43, R50, R67, R74 and R85) reviewed for resident/family group and response in the sample of 52.

Inspectors wroteBased on interview and record review, the facility failed to ensure hospital discharge instructions/physician's orders were followed after readmission to maintain the resident's highest practicable physical well-being for 1 of 3 residents (R2) reviewed for quality of care in the sample of 7. This failure resulted in R2 not receiving Lokelma, a medication to treat high levels of potassium in the blood. R2 was hospitalized with elevated potassium levels, shortness of breath, chest pains, and increased heart rate.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents (R4) reviewed for range of motion/mobility, in the sample of 7.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent resident to resident altercations in 3 of 6 residents (R9, R10, R11) reviewed for abuse in the sample of 11. This failure resulted in R11 becoming fearful and not feeling safe in her environment.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the state surveying agency in 1 of 6 residents (R3), reviewed for abuse in the sample of 11.

Inspectors wroteBased on interview and record review the facility failed to prevent abuse for 1 of 3 (R7) residents reviewed for abuse in a sample of 12. This failure resulted in R7 experiencing pain, being fearful, feeling trapped, unprotected, and feeling less than a man.

Inspectors wroteBased on interview and record review the facility failed to initiate its abuse policy and report allegations of abuse for 2 of 3 (R6, R7) residents reviewed for abuse, in a sample of 12. This failure resulted in R7 being fearful, feeling trapped, unprotected, and feeling less than a man. This failure also resulted in R6 feeling unsafe and as if no one cares.

Inspectors wroteBased on interview and record review the facility failed to properly investigate and prevent abuse for 1 of 3 (R7) residents reviewed for abuse, in a sample of 12. This failure resulted in R7 being fearful, feeling trapped, unprotected, and feeling less than a man.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent resident to resident abuse for 2 of 3 residents (R5, R6) reviewed for abuse in the sample of 18. This failure resulted in R6 being sent to the hospital for evaluation of a laceration on his face and R5 being sent to jail for assaulting R6.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatments to pressure ulcers as ordered by the physician for 2 of 2 residents (R10 and R11) reviewed for pressure ulcers in the sample of 18. This failure resulted in R10's pressure ulcer becoming infected and increasing in size.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral treatment and services to address the diagnoses of alcohol and/or substance abuse for 1 of 3 residents (R5) reviewed for behavioral services in the sample of 18. This failure resulted in R5 not receiving any substance abuse treatment or services. Subsequently, R5 returned from an outing intoxicated and physically assaulted R6, striking R6 in the face with a toilet plunger resulting in R6 being sent to the hospital for evaluation of a laceration on his face and R5 being taken to jail for assaulting R6.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for 4 of 4 residents (R1, R2, R4, and R8) reviewed for Pharmacy Services in the sample of 18.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatments to a diabetic ulcer as ordered by the physician for one of three residents (R9) reviewed for wounds in the sample of 18.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure a Director of Nursing was working full time in the facility. This has the potential to affect all 105 residents living in the facility.

Inspectors wroteBased on interview, record review, and observation the facility failed to provide a safe, clean, comfortable, and homelike environment due to toilets not working appropriately for 8 of 8 residents (R4, R5, R9, R10, R11, R12, R13 and R14) reviewed for plumbing issues in the sample of 14. Findings Include: R4's Minimum Data Set (MDS), dated [DATE] documents, R4 is cognitively intact. R5's MDS dated [DATE] documents, R5 is cognitively intact. R9's MDS dated [DATE] documents, R9 is cognitively intact. R10's MDS dated [DATE] documents, R10 is moderately cognitively impaired. R11's MDS dated [DATE] documents, R11 is cognitively intact. R12's MDS dated [DATE] documents, R12 is moderately cognitively impaired. R13's MDS dated [DATE] documents, R13 is moderately Cognitively impaired. R14's MDS dated [DATE] documents, R14 is cognitively intact. [...]

Inspectors wroteBased on interview and record review the facility failed to answer call lights in a timely manner for 3 of 3 residents (R2, R4, R8) reviewed for call lights in the sample of 14. Findings Include: 1. R2's MDS (Minimum Data Set) dated 12/31/23 documents R2 is cognitively intact. R2's MDS also documents, he is always incontinent of bowels. R2 has an indwelling catheter. R2's Care Plan dated 01/24/24 documents, R2 requires assist with daily care needs r/t (related to), his dx (diagnosis) of Paraplegia. He requires extensive to total assist to complete ADL's (Activity of Daily Living) at this time. On 01/23/24 at 9:00 AM R2 stated, yes depending on who is working you might get help or not. This past weekend I didn't have a CNA (Certified Nursing Assistant). They will ignore the call light or come in and shut it off and never come back. [...]

Inspectors wroteBased on observation, interview and record review, the Facility failed to adhere to their Medication Administration Policy, administer medications as prescribed by a physician, and ensure medications were administered safely for 3 of 4 residents (R1, R5 and R6) reviewed for medication administration in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to follow their Fall Prevention Policy by not providing proper notification for 1 of 3 residents (R1) reviewed for Policy and Procedure, in the sample of 7.

Inspectors wroteBased on interview and record review, the facility failed to follow their Fall Prevention Policy, investigate the root cause of a fall, as well as implement effective interventions for 1 of 3 residents (R1) reviewed for falls, in the sample of 7.

Inspectors wroteBased on interview and record review the facility failed to prevent resident to resident abuse for 1 of 4 residents (R2) reviewed for abuse in the sample of 16.

Inspectors wroteBased on interview and record review the facility failed to offer Influenza, COVID and Pneumococcal Vaccines to 4 of 5 residents (R1, R14, R15 and R16) reviewed for vaccinations in the sample of 16.

Inspectors wroteBased on interview and record review, the facility failed to follow it's abuse policy by failing to immediately report an allegation of abuse after becoming aware for 1 of 4 residents (R2) reviewed for abuse in the sample of 16.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide adequate pest control. This failure has the potential to affect all 99 residents residing in the facility.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide incontinent care in 1 of 3 residents (R8) reviewed for Activities of Daily Living Care (ADL) in the sample of 10.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide timely turning/repositioning in 1 (R8) of 3 residents reviewed for pressure ulcer prevention in the sample of 10.